HIV Testing: Time to Combat Missed Opportunities
Many at risk say they were not offered testing at last clinical visit
By Rebecca Bowers
Results of a recent national analysis suggest that many people who are infected with HIV but not aware of their infection were not offered HIV testing during recent clinical visits. The Centers for Disease Control and Prevention recommends testing at least annually for people who are at high risk for HIV infection, including men who have sex with men and injection drug users.
- It is estimated that in 2015, about 15% of persons in the United States who were living with HIV did not know they were infected. However, this same population accounted for about 40% of annual HIV transmissions.
- Tests can differ according to the type of specimen tested, such as whole blood, serum, or plasma; oral fluid; or urine.
Results of a recent national analysis suggest many people who are infected with human immunodeficiency virus (HIV) but unaware of their infection were not offered HIV testing during recent clinical visits.1 The Centers for Disease Control and Prevention (CDC) recommends testing at least annually for people who are at high risk for HIV infection, including men who have sex with men and injection drug users.
It is estimated that in 2015, about 15% of persons in the United States who were living with HIV were not aware they were infected. However, this same population accounted for about 40% of annual HIV transmissions.2,3
To conduct the current analysis, researchers looked at data from the National HIV Behavioral Surveillance, which evaluates biobehavioral data from populations at high risk in cities with high HIV burden. The scientists examined information about adults 18 years of age or older from 19 U.S. cities. The data about men who had ever had sex with another man (MSM) were collected in 2014. For men and women who had injected drugs (PWID) in the previous year, data were collected in 2012 and 2015, and were combined to make sure the estimates were stable.1 Participants reported if they had been tested for HIV, visited a clinician, or been offered an HIV test by a healthcare provider during the past year.
Of the 9,105 men who had ever had sex with another man, 22% had tested positive for HIV infection; 8% of the 19,357 men and women injecting drugs had positive test results. In looking at the HIV-positive participants, researchers found that 8% of MSM and 12% PWID were not aware of their infection. Further analysis of those unaware of their positive status shows that 81% MSM and 65% PWID reported visiting a healthcare provider in the past year. Of those who were not tested for HIV in the past year, 52% of men who have sex with men and 45% of injection drug users said they were not offered HIV testing, despite visiting a healthcare provider.1
Everyone, no matter their perceived risk, should be tested at least once for HIV, and those who are at a higher risk should be tested frequently, says Michael Ruppal, executive director of The AIDS Institute. Although progress has been made in HIV prevention, care, and treatment, HIV testing is “critical” in the fight against the pandemic, says Ruppal.
Review Testing Guidance
According to CDC guidance, all adults ages 13-64 should be tested for HIV, with repeated screening at least every year for those who have a higher risk.4 Gay and bisexual men who are sexually active may be helped by testing that is more frequent, for example every three to six months. At-risk behaviors include:
- engaging in unprotected vaginal or anal sex, including unprotected sex with MSM;
- engaging in unprotected sex with a partner who is HIV-positive or whose HIV status is unknown;
- injecting drugs or sharing equipment with others;
- providing sex in exchange for drugs or money;
- having a diagnosis of hepatitis, tuberculosis, or a sexually transmitted disease or receiving treatment for those conditions; or
- having unprotected sex with a person who has engaged in these behaviors.4
In addition, HIV testing is recommended in pregnant women and in newborns when the HIV status of the mother is unknown.4 If treatment is given to pregnant women who are HIV-positive and their infants for four to six weeks after delivery, the risk of transmission is reduced to 1% or less.5 Recommendations also call for HIV testing of anyone who has been sexually assaulted.
Who Is Getting Tested?
Results from a 2014 survey of U.S. adults ages 18-64 conducted by the Kaiser Family Foundation show that 54% of Americans had received testing for HIV, including 16% who indicated they had been tested in the past year. Although the percentage of the public who say they have received testing for HIV at some point has increased from 1997 and 2004, such numbers have remained constant, the foundation says.6
Results of a 2014 Kaiser Family Foundation survey of gay and bisexual men in the United States show that while seven out of 10 indicate they have been tested for HIV during their lives, just one in five reported they had been tested in past six months.7 About 33% said they had never been tested, with 44% younger than 35 years of age reporting such untested status.
Review Test Options
What type of HIV testing is used in your practice setting? Tests can differ depending on type of specimen that is tested, whether it is whole blood, serum, or plasma; oral fluid; or urine. Test specimens may be collected by a blood draw or venipuncture, finger prick, oral swab, or via urination. Tests may be processed in the lab, at point of care, or at home, with result times ranging from conventional to rapid.
Conventional blood tests involve a sample drawn by a healthcare provider, with results tested in a lab. The test results typically can be available within an hour to several days.
With an oral fluid sample, a swab inside the mouth is collected by a healthcare provider, with results available in days to about two weeks. Avioq is the only HIV test of oral fluid that is approved by the Food and Drug Administration (FDA). The test is used with OraSure, an oral fluid collection device approved by the FDA.
Many providers look to rapid tests for HIV tests, since results can be ready in less than 10 minutes. When test results are negative, further testing is not needed; however, positive test results require confirmation using conventional methods.
Eight rapid tests approved by the FDA are available:
- OraQuick Advance Rapid HIV-1/2 Antibody Test, which uses whole blood from a finger prick or venipuncture, plasma, or oral fluid;
- Reveal Rapid HIV-1 Antibody Test, which uses serum or plasma;
- Uni-Gold Recombigen HIV Test, which uses whole blood from a finger prick or venipuncture, serum, or plasma;
- Multispot HIV-1/HIV-2 Rapid Test, which uses serum or plasma;
- NSTI HIV-1 Antibody Test, which uses whole blood finger prick, venipuncture, or plasma;
- Alere Determine HIV-1/2 Ag/Ab Combo Test, which uses serum, plasma, whole blood finger prick, or venipuncture;
- Clearview HIV 1/2 Stat Pak and Clearview Complete HIV 1/2, which both use whole blood, serum, or plasma.
Some of the rapid tests have received regulatory waivers that allow them to be used outside of traditional laboratories.
- Wejnert C, Prejean J, Hoots B, et al. Prevalence of missed opportunities for HIV testing among persons unaware of their infection. JAMA 2018;319:2555-2557.
- Gopalappa C, Farnham PG, Chen YH, et al. Progression and transmission of HIV/AIDS (PATH 2.0). Med Decis Making 2017;37:224-233.
- Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2010-2015. HIV Surveillance Supplemental Report 2018;23(No.1). Available at: . Accessed July 19, 2018.
- Branson BM, Handsfield HH, Lampe MA, et al; Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006;55(RR-14):1-17.
- Centers for Disease Control and Prevention (CDC). HIV Among Pregnant Women, Infants, and Children. Accessed at .
- Henry J. Kaiser Family Foundation. HIV Testing in the United States. June 27, 2018. Available at: . Accessed July 19, 2018.
- Hamel L, Firth J, Hoff T, et al. Henry J. Kaiser Family Foundation. HIV/AIDS in the Lives of Gay and Bisexual Men in the United States. Sept. 25, 2014. Available at: . Accessed July 19, 2018.
Results of a recent national analysis suggest that many people who are infected with HIV but not aware of their infection were not offered HIV testing during recent clinical visits.
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